“Woman doctor stabbed to death by a patient in Kerala hospital”; “Hyderabad doctors attacked in hospital by attendants after patient dies.” Last year, a doctor in Rajasthan died by suicide. She hung herself to death, allegedly after she was booked for the murder of a pregnant woman who didn’t survive her delivery.

These are not isolated incidents. There has been a significant increase in news reports from around the country of doctors and other healthcare workers facing violence at the hands of people who recently lost a loved one, and blame healthcare personnel for improper care.

In the majority of such cases (60-70%), violence takes the form of either verbal abuse or aggressive gestures. Very often, those who abuse a medical person are patients themselves. They are under the influence of alcohol and drugs and are delirious. Increased risk of violence is particularly recorded during the night.

More often than not, patients by themselves are not violence makers, but their relatives are. Sometimes unknown apparently sympathetic individuals, politicians and political parties take the law in their hand.

Important dimensions of violence to the doctors in government and corporate hospitals are:

• India spends close to 2% of the total budget on health care, which is dismal when compared to other countries. Due to poor insurance penetration, especially in small hospitals (which play a dominant role in health care delivery in India) the patient has to pay from his/her own pocket to the point of catastrophic poverty. As a result, small medical establishments are particularly susceptible to violence and aggression at the time of billing.

• Feeling of wrongdoing by the doctors for financial gain or for avoiding his/her duties.

• Anxiety, long waiting periods before the patient could speak to a doctor and the feeling that the doctor is not giving enough attention to his/her patients give rise to frustration, leading to violence.

• Majority of the hospitals in India do not have a good grievance redressal system in place.

• Legal procedure in India also takes inordinately long time.

The doctor to population ratio in India is 1 to 1456, far more than the WHO’s recommendation for 1 to1000. Therefore, even if a single doctor is injured, it could be fatal for more than 1,456 patients, further burdening the healthcare system.

What can a doctor do to avoid violence? A doctor should understand some of those patient-related characteristics which may be associated with violence. These include background psychological disturbance or substance abuse, heightened anxiety about the disease, as well as finances needed for treatment. These factors seem to be an important component of initiation of violence, and the doctor should train himself/herself in anxiety alleviation techniques.

Bereavement, young patients under serious condition, and children with serious disease evolve emotional outburst which may quickly end in violence. Long waiting hours and doctor's behaviour towards patients and relatives are important contributors to aggression and need to be addressed by the doctor as much as possible.

Also, self-defence training for medical workers can also be helpful in dealing with the ongoing trend of violence against the medical staff. In hospitals, there can be general reform for the hospital services in the form of: (i) Improvement of services in a global fashion; (ii) employment of adequate number of doctors and other steps to ease the rush of patients and long waiting hours; (iii) use of computer and internet technology; (iv) hospital security should be strengthened and it needs to be properly interlocked with nearby police station; (v) no arms/ammunition by patient or their relatives should be allowed inside the hospital; (vi) there should be transparency on rates of different investigations, rents and other expenses in the hospital; and (vii) there should be a proper complaint redressal system in the hospital.

There is a huge responsibility of patients, their relatives and society at large to prevent this violence. Disputes between patients and hospitals or doctors are not to be sorted through violence, but in a civilised society, there are avenues of dispute redressal which should be used.

Modern medicine is neither cheap nor 100 percent effective in curing the disease in all cases. There should not be an under-expectation on the outcome of the treatment in a serious case. Some patients will make it, some patients will not. This should be clearly understood.

There should be an understanding that vandalism and violence in a hospital or clinic is a criminal offense. any civilised society should have low tolerance for such heinous acts. Hardly are any social leaders seen condemning such violence today, , and surprisingly sometimes they even try to justify the situation.

What is the responsibility of the government and political parties? Spending around 1 percent of the GDP by the government on a population which increased five times since Independence is not enough. The government needs to put in the effort to see how overcrowding in the hospitals can be prevented.

The government should concentrate its activities on preventive medicine. No nation can build hospitals for 1300 million patients, but it is possible to build resources for 1300 million citizens who are largely healthy. Nutrition, immunisation, health education, pollution control, personal hygiene, access to clean water, unadulterated milk, unadulterated food, facilities for exercise, playground, etc. are the basic requirements. more emphasis needs to be put on their availability.

The government should punish unlawful behaviour of anybody who harms the doctor and vandalises the hospital. During the COVID 19 pandemic, there was a temporary respite, when the Indian government introduced an ordinance called ‘The Epidemic Disease(Amendment) Ordinance’ in 2020. As its name suggests, the ordinance amended the Epidemic Diseases Act 1897, which the health ministry had invoked as the pandemic began.

The change created a provision to levy those convicted of harassing or assaulting a healthcare worker a fine of Rs 50,000 to Rs 2 lakh and imprisonment for three months to five years. In case the injury inflicted on the healthcare worker was serious, the convicted person would have to pay a higher fine and/or spend more time in prison.

The catch here is that the government will revoke the Epidemic Diseases Act once the pandemic ends. At which point there will be no national law to deter violence against healthcare workers. Hence, stringent government policies to protect the healthcare workers still do not exist in India.

Although violence against doctors and other health workers is not uncommon, the incidence in India seems to be increasing. Many remedies have been advised to tackle this situation, some of those are discussed here.

There are certain responsibilities of doctors and other healthcare workers, similarly, responsibilities also have to be borne by patients, their relatives, political parties, hospital authorities, law maintaining machinery, media and government to see that health care improves and violence against doctors is strongly dealt with.

It’s even more essential for the government to realise that health care infrastructure needs a massive boom. And it must ensure that the population to doctor ratio is improved, which can be done by effectuating policies for equitable education in medicine.

Every citizen needs to be moved by the incidents of violence that have been reported and express solidarity to those on the frontline. There is no reason to wait now to stop this violence against doctors. take preventive measures.

Beating up doctors and other healthcare professionals could bring down the optimism of young medical aspirants. The profession can be extremely taxing both mentally and physically, and such instances may deter young doctors from pursuing their oath.

Dr Manali Agarwal is a Senior Resident,Department of Microbiology, AIIMS, Delhi